System and method for use of acoustic reflectometry information in ventilation devices

ABSTRACT

The present disclosure relates to a system and method for use of acoustic reflectometry information in ventilation devices. The system and method includes a speaker to emit sound waves into an intubated endotracheal tube (“ETT”) and a microphone to detect returning acoustic reflections. In addition, the system and method includes a reflectometry device in communication with a ventilation device for analyzing timings and amplitudes of the returning acoustic reflections to determine a size of a passageway around an ETT tip, location and size of ETT obstructions, and relative movement of the ETT tip within a trachea. The reflectometry device is also configured to determine a resistance parameter representative of resistance to actual flow of air through the ETT based upon a function of the diameter of the ETT, length of the ETT, and percent obstruction of the ETT, where the resistance parameter is used to calculate the tracheal pressure,

I. CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No.61/617,249 filed Mar. 29, 2012. The disclosure of the provisionalapplication is incorporated herein by reference.

II. FIELD

The present disclosure is generally related to a system and method foruse of acoustic reflectometry information in ventilation devices.

III. DESCRIPTION OF RELATED ART

When a hospital patient is unable to breathe on his own, the patient isconnected to a mechanical ventilation device. The patient is firstintubated, a procedure in which an endotracheal tube (also called anartificial airway, endotracheal tube, or ETT), is inserted through thenose or mouth into the trachea (wind pipe). The tube is then connectedto a mechanical ventilation device, which forces air into the lungs.

Each year, approximately 60 million intubations requiring endotrachealtubes are performed worldwide. Assuring proper placement of theendotracheal tube within the trachea and assuring that it has not movedor become obstructed are significant clinical problems. Failure tocorrect a misplaced or clogged endotracheal tube can lead to seriouscomplications to the patient, most notably conditions consistent withlack of oxygen such as brain damage or death,

Complications with endotracheal tubes include:

Unplanned Extubation: The endotracheal tube unexpectedly comes out ofthe patient's trachea. Unplanned extubation has an incidence rate of 10%in adult ICU patients.

Endobronchial Intubation: The endotracheal tube is placed too far downinto the trachea, past the first branching, and enters a main stembronchus (the airway pipe which leads to one of the two lungs) or, afterproper positioning, patient movement or other factors cause the tube toadvance into a bronchus.

Endotracheal Tube Obstruction: Lung secretions or other substances blockthe tube, the tube kinks in the patient's throat, or the patient bitesexcessively on the tube.

Esophageal intubation: The endotracheal tube is accidentally insertedinto the esophagus (food pipe) instead of the trachea.

There are known in the art devices that provide direct, precise,real-time monitoring of endotracheal tube (ETT) position andobstructions, Systems and methods for doing this are disclosed in U.S.Pat. Nos. 5,445,144 and 6,705,31 to Wodicka et al. One such commerciallyavailable system is the SonarMed® AirWave™ system (available frontSonarMed, Inc., 5513 W. 74th Street, Indianapolis, Ind. 46268). Suchprior art devices and methodologies are collectively referred to hereinas an “acoustic reflectometry system.” The acoustic reflectometry systemcouples in-line between the ETT and the ventilator hose.

The acoustic reflectometry system's sound waves monitor the artificialy, alerting clinicians in real time of situations that may lead tounplanned extubations, ETT obstructions, endobronchial intubation, oresophageal intubation. Using principles similar to sonar, the acousticreflectometry system sends a sound signal into the ETT and records thereturning echoes that arise from within the tube and patient airways.The timing and amplitude of these echoes are analyzed by the system tonon-invasively measure:

Passageway Size Around ETT Tip: The system analyzes the echo that comesfrom the tube tip to estimate the size of the passageway relative totube diameter. This information may help clinicians identify and correctesophageal intubation and endobronchial intubation.,

Degree and Location of Obstructions Within the ETT: The system analyzesthe timing and amplitude of echoes that come from within the tube toestimate the location and size of obstructions. This may help cliniciansidentify an obstruction that forms in the endotracheal tube so it can beremoved before the patient is harmed. It may also help the cliniciandifferentiate patient biting or tube kinking from lung secretion buildupby noting the reported location of the obstruction.

ETT Tip Movement: The system estimates relative movements of the tube bytracking the timing of an echo that comes from within the lungs. Thisinformation may help clinicians identify and correct situations that canlead to unplanned extubation or endobronchial intubation.

Clinicians may use this information to assist with placing the ETTproperly and to receive early warnings about tube movement andobstruction development so they may take corrective action to preventpatient harm,

An acoustic reflectometry system consists of an adapter connected to theproximal end of an ETT and to a monitor. Embedded inside the adapter isa sound generator such as a miniature speaker, for example, and at leastone receiver such as a microphone array, for example. With thesecomponents, the system employs acoustic reflectometry by emitting soundwaves from the speaker into an intubated ETT, detecting the returningacoustic reflections, or echoes, with the microphones, and thenexamining the echo timings and amplitudes to infer characteristics ofthe ETT and airway. The system's algorithms analyze the echo signal andprovide information about the size of the passageway around the ETT tip,location and size of ETT obstructions, and relative movement of the ETTtip within the trachea.

The microphone array allows the system to determine the direction fromwhich echoes arrive. As a result, the system can selectively filter allechoes that arise from devices on the ventilator side of the adapter,such as closed circuit suction catheters, Y-connectors, ETCO₂ sensors,and filters, for example. This selective filtering allows the system toobtain an echo waveform from the Ell and airways that is free ofventilator circuit echoes.

The human airways are a network of bifurcating branches starting at thetrachea and ending at the alveoli—the small sacs where the oxygen andcarbon dioxide exchange takes place. An interesting property of theairways is that even though the cross sectional area of each individualsegment decreases as the branching depth increases, the total crosssectional area (arrived at by adding up the cross sectional areas of allparallel segments) undergoes a rapid increase after several generationsof airway branching. In other words, the airways behave acousticallylike a horn with a bell at the end, and sound waves traveling down theairways will be reflected at the hell. The negative pressure wave fromthis bell-shaped region is used by the system as a reference to whichchanges in ETT tip position are tracked. The bell begins around the 6thbranching generation (approximately 5 cm past the carina in adults).

There is no echo from the carina that can be tracked. Unfortunately,since the additive cross sectional area of the two main stem bronchi isapproximately equal to the trachea's cross sectional area, there are noechoes of significance that arise from the carina.

While a majority of medical devices that use acoustics operate in theultrasonic frequency range, the acoustic reflectometry system operatesin an audible range below 8 kHz because of the frequencies at whichtubes behave as waveguides. Since the sounds typically found in theventilator circuit—such as respiratory sounds, secretion sounds, or cuffleak sounds—can potentially interfere with the echo signals used by thesystem, a series of advanced data collection algorithms are used toobtain a clean echo signal during ventilation.

When connected to a patient, he acoustic reflectometry system collects amajority of its measurements during the quiet period of ventilationbetween end expiration and inspiration. As a result, the acousticreflectometry system monitor provides updates to the ETT statusapproximately every patient breath, depending on the level of noisepresent between breaths. For cases where excessive noise interferes withacoustical measurements such that the ETT status is not updating, theacoustic reflectometry system gives the clinician the option to listendirectly to the adapter microphones via the monitor speaker. Thisassists the clinician in determining the interfering noise source sothey can rectify it if possible. Examples of interfering noise sourcesmay include: a leaky ETT cuff, secretions in the airway and/or ETT, ahigh respiratory rate, a nebulizer, or patient coughing.

A shortcoming of the prior art ventilation device described above isthat the ventilation device does not have specific informationpertaining to the condition and location of the ETT in the patient.Consequently, if the ventilation device had access to acousticreflectometry information, the performance of the ventilation devicecould be improved.

However, in view of the prior art at he time the present invention wasmade, it was not obvious to those of ordinary skill in the pertinent arthow the identified needs could be fulfilled.

IV. SUMMARY

A system and method for use of acoustic reflectometry information inventilation devices is disclosed. The system and method of the presentdisclosure includes information about the artificial airway that can beused by other medical devices monitoring the patient or patient airwaysto enhance the device's performance and the patient's quality of care.These enhancements include improving ventilation modes thatautomatically compensate for ETTs by using obstruction information toestimate breath by breath ETT resistance, providing additional insightsto the clinician regarding patient work of breathing which may lead toimproved outcomes of weaning the patient from the ventilator, improvingtreatment efficacy by making alarms more specific and directing theclinician to the most likely source causing the alarm, trending ETTposition and patency information in concert with ventilation trendedvariables to make it easier to determine correlations between artificialairway issues and the patient airway status, improving secretionmanagement by using trend of estimated ETT resistance to determine ifsuctioning is recommended and. comparing estimated ETT resistance pre-and post-suctioning to determine efficacy of suctioning; and reducingnuisance alarms by detecting patient events such as coughing anddirecting the ventilator to ignore the event instead of issuing a highpressure alarm.

In a particular illustrative embodiment, the system includes a soundgenerator to emit sound waves into the ETT and at least one receiver todetect returning acoustic reflections. The system also includes areflectometry device having at least one processor and a memory that isaccessible to the processor for analyzing timings and amplitudes of thereturning acoustic reflections to determine a size of a passagewayaround an ETT tip, location and size of ETT obstructions, and relativemovement of the ETT tip within a trachea. In addition, a ventilationdevice is in communication with the reflectometry device.

Additional objects, features, and advantages of the present disclosurewill become apparent to those skilled in the art upon consideration ofthe following detailed description of a preferred embodimentexemplifying the best mode of carrying out the teachings of the presentdisclosure as presently perceived.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagrammatical view illustrating proper insertion of anendotracheal tube (“ETT”) into a trachea of a human body;

FIG. 2 is a diagrammatical view of sound waves and acoustic reflectionsmoving within the ETT;

FIG. 3 is a diagrammatical view of the sound waves and respective echosignals (i.e., acoustic reflections) after encountering changes in crosssectional area in a tube;

FIG. 4 is a diagrammatical view illustrating relationships between crosssectional area, amplitude, and time delay of an acoustic reflectometrysystem;

FIG. 5 is a diagrammatical view of a device of the system having adisplay, a processor and a memory that is accessible to the processor;and

FIG. 6 is a diagrammatical view of an adapter of the system that insertsinto the breathing circuit between the ventilator hose and the ETT.

VI. DETAILED DESCRIPTION

For purposes of promoting an understanding of the principles of themethod and system, reference will now be made to the embodimentillustrated in the drawings, and specific language will be used todescribe that embodiment. It will nevertheless be understood that nolimitation of the scope of the method and system is intended.Alterations and modifications, and further applications of theprinciples of the method and system as illustrated therein, as wouldnormally occur to one skilled in the art to which the method and systemrelates are contemplated, are desired to be protected. Such alternativeembodiments require certain adaptations to the embodiments discussedherein that would be obvious to those skilled in the art.

Referring now to the drawings, FIGS. 1 and 2 illustrate proper insertionof an ETT 102 into the trachea 104 For proper mechanical ventilation ofthe patient 106, it is important that distal end of the ETT 102 ispositioned properly within trachea 104 between vocal folds and thecarina to provide adequate ventilation to both lungs 108. The acousticreflectometry system adapter 110 couples between the ETT 102 and theventilator hose 112 as shown in FIG. 1. The acoustic reflectometrysystem's sound waves monitor the artificial airway, alerting cliniciansin real time of situations that may lead to unplanned extubations, ETTobstructions, endobronchial or esophageal intubation. The adapter 110 isconnected by a cord 114 (or wirelessly) to a device 122 to analyzesignals from the system.

As shown in FIG. 2, the system uses principles similar to sonar as theacoustic reflectometry system sends a sound signal 116 into the FIT 102and records the returning echoes 118 that arise from within the tube 102and patient airways. The timing and amplitude of these echoes 118 areanalyzed by the system to detect obstructions 120.

Referring now to FIG. 3, as a sound wave travels inside a tube, afraction of its energy reflects each time it meets with a change incross sectional area. If it encounters a decrease in cross sectionalarea (see FIG. 3(a)), a positive pressure wave is reflected. This showsup as a positive deflection in the echo signal. If the sound waveencounters an increase in cross sectional area (see FIG. 3(b)), anegative pressure wave is reflected. This shows up as a negativedeflection in the echo signal. The delay time of each echo identifiesthe distance from the microphone to the changing area that caused theecho. The amplitude of each echo identifies the approximate amount ofarea change.

To illustrate the relationships between cross sectional area, amplitude,and time delay, FIG. 4 shows an intubated ETT (top) with itscorresponding echo signal, as recorded by the acoustic reflectometrysystem (bottom). The pressure amplitude is represented on Y-axis and thetime delay is represented on X-axis. For each deflection in the echosignal, an arrow denotes the corresponding region in the ETT and airwaysfrom which that echo arises.

The first echo is a positive deflection (positive pressure) indicating across sectional area decrease. This corresponds to the decrease in thenozzle's diameter from 9 mm to 8 mm. The second echo is a positivedeflection immediately followed by a negative deflection, indicating across sectional area decrease and then an increase. This echo could befrom a small obstruction in the ETT, from a kink in the ETT, or from apatient biting on the ETT. If the echo amplitude were larger, this wouldcorrespond to a larger obstruction. The acoustic reflectometry systemestimates the obstruction size from the echo amplitude and theobstruction location from the echo delay time.

The third echo is a negative deflection indicating a cross sectional eaincrease. This echo, referred to as the ETT tip echo, is analyzed by theacoustic reflectometry system to estimate the passageway size (oreffective diameter) around the ETT. A negative deflection echo indicatesthat the ETT is located in a passageway that has a larger crosssectional area than the ETT. This would be the. case for an EFT that isin the trachea. If this echo were to change to a positive deflection, itwould indicate that the ETT is located in a passageway that has asmaller cross sectional area than the ETT. This may correspond to an ETTthat is in the esophagus or bronchus or that it is clogged at the tip,for example, from mucus.

The last echo, referred to as the airway echo, arises from the bellshaped region in the lower airways. The acoustic reflectometry systemtracks the time delay of this airway echo, estimating relative changesin the distance between the ETT tip and the airway echo region. Forexample, if the time delay between the ETT tip echo and the airway echois decreasing (airway echo moving to the left), then this indicates thatthe ETT tip is getting closer to the airway echo region or that the ETTis migrating down the trachea.

Referring now to FIGS. 5 and 6, the acoustic reflectometry systemincludes a device 122. that is a handheld, portable device with adisplay 124 that provides information about the endotracheal tubeposition, obstruction, and movement. The device 122 has at least oneprocessor and a memory that is accessible to the processor. The device122. may include circuitry for sending, receiving and processing audiosignals from the acoustic reflectometry system adapter 110 via cable114. As explained below, the acoustic reflectometry system interpretsthe signals received from the patient's airway and provides feedback tothe clinician through intuitive text and graphics.

Many improvements may be made in the operation of ventilators and otherdevices by obtaining information that may be gleaned from airwaymonitoring devices such as the acoustic reflectometry system disclosedherein and using this data and new algorithm to improve prior artventilator functionality as described below.

Improvement in the Calculation of P_(TRACHEA) (Pressure Within Trachea)

The pressure within the trachea can be calculated by a ventilator asfollows:

P_(TRACHEA)=P_(AW)−ΔP_(TUBE)

ΔP_(TUBE)=R_(TUBE)×Flow

where P_(TRACHEA)=estimated tracheal pressure,

P_(AW)=measured mean pressure at the Y-piece,

ΔP_(TUBE)=estimated pressure drop across ETT,

R_(TUBE)=estimated ETT resistance (pressure differential across tube),

Flow=measured airway flow,

As explained above, in the prior art the calculation of R_(TUBE) is afunction of ETT diameter (d_(ETT)) and length (l). The prior artcalculation of the estimated ETT resistance assumes an ideal tube forthe ETT. However, in reality there are often obstructions within the ETTthat can present a significant obstacle to the flow of air through thetube. The estimated ETT resistance may therefore be improved by usingETT monitoring data that can detect obstructions within the ETT, therebyallowing the calculation of R_(TUBE) as a function R_(TUBE)(d_(ETT), l,Pct1, Pct2), which additionally takes into account percent of ETTobstruction 1 and 2. (Pct1 and Pct2, the two largest obstructions withinthe ETT). The figures for percent of ETT obstruction 1 and 2 (Pct1 andPct2) comprise an estimate of what percent of the total ETT tubediameter is obstructed by each obstruction. Those skilled in the artwill recognize that fewer or more than two tube obstructions may betaken into account. In fact, the acoustic reflectometry system candetect the whole obstruction profile within the ETT from the proximalend to the distal end and an effective tube diameter can be calculatedbased upon this data. The more accurate tube diameter measurement willallow for a more accurate estimate of the ETT tube resistance, and hencea more accurate estimate of P_(TRACHEA).

Improvement to Automatic Tube Compensation

Work of breathing (WOB) is a measure of how much work an intubatedpatient has to do to inhale and exhale, and is used to determine if apatient will be able to breathe on their own if the ventilator isremoved. An increase in R_(TUBE) (tube resistance or the pressure acrossthe tube) increases WOB. Automatic Tube Compensation (ATC) or AutomaticAirway Compensation (AAC) is a technique used on the Draeger® Evita®(available from Draeger Medical, Inc., 3135 Quarry Road, Telford, Pa.18969) Mallinekrodt® 840 (available from Covidien, 15 Hampshire Street,Mansfield, Mass. 02048), and Viasys® Avea® (available from CareFusionCorporation, 3750 Torrey View Court, San Diego, Calif. 92130)ventilators, which overcome the imposed work due to the ETTautomatically, based on the known resistive characteristics of the ETTand the measured inspiratory flow. This technique is similar to theresistive component of proportional assist ventilation (PAV). ATC hasbeen shown to reduce the imposed work of breathing due to the artificialairway more reliably than pressure support ventilation.

For ATC, the patient is spontaneously breathing and, depending on theflow volume, the ventilator calculates the pressure in the trachea andthen assists the patient by setting the pressure at the proximal end ofthe ETT so that the calculated pressure in the trachea (i.e., after thepressure drop caused by the ETT) is at the pressure that would bepresent during normal breathing without an ETT Therefore, when the.patient tries to spontaneously breathe, the ventilator senses a pressuredrop and then increases the pressure at the proximal end of the ETT tocompensate for the pressure drop. Setting “% tube compensation” on theventilator to zero results in no compensation. Setting the “% tubecompensation” to 100 provides full compensation for the ETT.

A typical operating sequence for initiating ATC is as follows:

1. The ventilator uses known constants for R_(TUBE) for different sizeendotracheal and tracheostomy tubes stored in a look-up table.

2. The operator inputs the tube size and % tube compensation desired.The ventilator uses the mathematical model to simulate tracheal pressurecontrol.

3. The ventilator also displays the calculated tracheal pressure.

4. The equation for tube compensation is P_(TRACHEA)=P_(AW)−R_(TUBE)×Flow, where P_(TRACHEA)=tracheal pressure,P_(AW)=mean pressure at the Y-piece, R_(TUBE)=tube coefficient, Flow=airway flow.

This prior art technique suffers from the following pitfalls:

1. Airway secretion, or position changes may result in undercompensation, since the calculated P_(TRCHEA) has not taken thesefactors into account.

2. In vivo resistance is greater than ex vivo resistance,

3. Following extubation, upper airway changes may affect work ofbreathing unanticipated by tube compensation.

As described hereinabove, the obstruction information available from theacoustic reflectometry system may he used to improve the P_(TRACHEA)estimate.

Improvements to Pressure Support Ventilation

Pressure support ventilation (PSV) is a ventilator mode that allows theuser to select an elevated pressure during spontaneous inspiration tosupport breathing by overcoming the pressure drop across the ETT. Thisis somewhat similar to ATC, but instead the operator selects a constantpressure for support instead of the ventilator automatically calculatingthe pressure based on flow volume. Therefore, when selecting this mode,the user can use the real-time P_(TRACHEA) calculated as describedhereinabove as direct feedback to determine the appropriate pressureassist level, For example, while observing the real-time tracheapressure waveform, the user can adjust the pressure support level toobtain a trachea pressure that is above, at, or below a desired baselinepressure, depending on the amount of work the caregiver determines isappropriate as the patient progresses through the ETT weaning process.

Improvements to Adaptive Ventilation Modes

The process of gas delivery to the patient depends on the mode ofventilation (see below). Typically a breath can be classified as eithervolume controlled or pressure controlled, depending on which variablethe ventilator actively controls during ventilation.

Volume ventilation—A predetermined tidal volume (V_(t)) is set by theclinician, and is delivered to the patient every time a breath istriggered. For example, if the tidal volume is set at 500 ml theventilator will continue inspiration until 500 ml have been delivered tothe patient. Upon completion of inspiration, the ventilator will cycleto exhalation. The amount of pressure necessary to deliver the tidalvolume is determined by the resistance and compliance of the patient andventilator circuit, and may vary from breath to breath.

Pressure ventilation—A predetermined peak inspiratory pressure (PIP) isset by the clinician and delivered to the patient throughout the setinspiratory time (T_(t)). After the inspiratory time has elapsed, theventilator will cycle to expiration. The tidal volume delivered to thepatient is determined by the resistance and compliance of the patientand circuit, and may vary from breath to breath.

Pressure regulated volume control—Several ventilator manufactures haveincorporated features from both of these modes. These modes arenow-variable, volume-targeted, pressure-regulated and time-limited. Thismeans that instead of providing an exact tidal volume each breath, atarget volume is set and the ventilator will vary the inspiratorypressure (PIP) on a breath to breath basis to achieve that volume. Aswith pressure ventilation, the inspiratory time (T_(t)) limits thelength of the inspiratory cycle. The primary benefit from such modes isthat they allow the set tidal volume to be achieved with the lowestpossible peak inspiratory pressure.

Exhalation in mechanical ventilation is almost always completelypassive. The ventilator's expiratory valve is opened, and expiratoryflow is allowed until the baseline pressure (positive end-expiratorypressure, or PEEP) is reached. Expiratory flow is determined by patientfactors such as compliance and resistance.

In Adaptive Support Ventilation (ASV), Inspiratory Pressure is thepressure above PEEP to be applied in the next breath. This pressure ismeasured at the proximal end of the ETT, Inspiratory pressure isadapted, breath by breath, to gently drive the tidal volume towards theV, target.

ASV delivers the optimal tidal volume using the lowest pressurespossible using the following steps:

1. Assess breath by breath the patient's lung mechanics.

2. Optimize breath by breath the tidal volume/respiratory frequencycombination based on lung mechanics.

3. Achieve optimum tidal volume/respiratory frequency by automaticallyadjusting mandatory rate and inspiratory pressure.

By using the much more accurate R_(TUBE) resistance information that ismade possible by the acoustic reflectometry system as discussed above,the much more accurate breath by breath estimation of ETT resistance canbe used to help improve the estimate of patient lung mechanics (bybetter characterizing the contributions of the ETT to the overallmechanics). The R_(TUBE) resistance information from the acousticreflectometry system may therefore advantageously be made available tothe ventilator controller that is assessing the patient's lung mechanicsand. adjusting the ventilator's mandatory rate and inspiratory pressurein order to improve optimization of tidal volume and respiratoryfrequency.

Use of P_(TRACHEA) to Inform Selection of Ventilation Settings

As discussed above, pressure support ventilation (PSV) is a ventilatormode which allows the user to select an elevated pressure duringspontaneous inspiration to support breathing by overcoming the pressuredrop across the ETT. This is somewhat similar to ATC, but instead theoperator selects a constant pressure for support instead of theventilator automatically calculating the pressure based upon flowvolume. Therefore, when selecting PSV, the user can use the real-timetrachea pressure (P_(TRACHEA)) as direct feedback to determine theappropriate pressure assist level. For example, while observing thereal-time trachea pressure waveform, the user can adjust the pressuresupport level setting on the ventilator to obtain a trachea pressurethat is above, at, or below a desired baseline pressure, depending onthe amount of work the caregiver determines is appropriate as thepatient progresses through the ventilator weaning process.Alternatively, the user may set the desired trachea pressure (above, at,or below a desired baseline pressure), and the ventilator controller,which is provided access to the P_(TRACHEA) data from the acousticreflectometry system, may automatically adjust the pressure supportlevel setting on the ventilator to obtain the desired trachea pressure.

Assessing a Patient's Readiness for Weaning

In the prior art, the determination of a patient's readiness for weaningoff of a ventilator is assessed by a number of methods, one of whichconsists of reducing ventilator support to the level that it onlyovercomes the WOB intrinsic to the artificial airway. If, for anextended period of time prior to extubation, the patient is able tosustain the effort necessary for full spontaneous breathing while theventilator support level is only overcoming the WOB caused by theartificial airway, extubation is indicated.

Use of measurements from the acoustic reflectometry system inconjunction with the support modes available in ventilators, cansignificantly increase the validity of the “extubation simulation” (or“electronic extubation”) to more accurately reflect a patient'slong-term ability to breathe without the help from a ventilator, andmake this type of weaning trial a more integral part of the naturalprogression of a treatment protocol. During electronic extubation, thepressure at the top of the ETT is set so that the pressure at the bottomof the ETT is the pressure that the patient would experience if theywere breathing on their own (i.e., the ventilation is compensating onlyfor the effect of the ETT, hence the ETT is said to have beenelectronically extubated). One embodiment, two sets of WOB parametersare displayed on the ventilator, one that depicts the actual WOB shareof the patient versus the ventilator, and one that gives the sameparameters under “free airway” conditions as calculated from thecontinuous information of tube resistance (R_(TUBE)) that is availablefrom the acoustic reflectometry system.

Ability to Suggest Cause of High Pressure Alarm

During a high pressure alarm issued by the ventilator, it is possible toprovide more specific alarm language to the user based upon informationthat can be supplied to the ventilator controller from the acousticreflectometry system. The data received from the acoustic reflectometrysystem can then be used to diagnose the cause of the high pressurecondition, giving the user insight into how to correct the problem thatis causing the alarm. Examples of high pressure alarm information thatcan be transmitted to the user based upon information made available bythe acoustic reflectometry system include:

1. Partial obstruction detected in Err;

2. ETT tip partially occluded; and

3. Possible mainstem bronchial intubation (indicated by the size of thepassageway detected around the ETT tip).

Ability to Suggest Cause of Low Volume Alarm

During a low volume alarm issued by the ventilator, it is possible toprovide more specific alarm language to the user based upon informationthat can be supplied to the ventilator controller from the acousticreflectometry system. The data received from the acoustic reflectometrysystem can then be used to diagnose the cause of the low volumecondition, giving the user insight into how to correct the problem thatis causing the alarm. Examples of low volume alarm information that canbe transmitted to the user based upon information made available by theacoustic reflectometry system include:

1. Possible mainstem bronchial intubation (indicated by the size of thepassageway detected distal of the ETT tip);

2. Possible collapsed lung (indicated by a significant change in theairway sonic reflection morphology, which is a composite of thereflection coming from both the left and right lungs—change one lungvolume and the composite signal will change significantly);

3. Possible bronchial plug (indicated by a significant change in theairway sonic reflection morphology, which is a composite of thereflection coming from both the left and right lungs—a plugged bronchusof one lung will significantly change the composite signal).

Integration of Acoustic Reflectometry System Data into Hierarchy ofVentilator Alarms

Ventilator alarms are calling for intervention when a physical conditionbeen recognized that directly threatens the well-being of a patient.However, in the way alarms and their hierarchies are implemented inventilators in the prior art, they are also used to improve treatmentefficacy by directing the clinician to the most likely source causingthe alarm. Using data available from the acoustic reflectometry system,an airway resistance threshold alarm may be created that will beactivated before any high pressure alarms would be triggered,effectively giving the clinician an opportunity to solve the problembefore a high pressure condition occurs.

Integration of Acoustic Reflectometer into Ventilator/Hose

An acoustic reflectometer as referenced herein may be integrated intothe ventilator at the hose connection or in the hose itself. Thisacoustic reflectometer may be used to detect hose faults and otherconditions:

1. Location and severity of hose kinking;

2. Location and severity of hose occlusion due to rainout (the poolingof condensation in a low point of the hose);

3. Hose partial or full disconnection location; or

4. Detect presence/absence of airway circuit devices (filters, etc).

It will be appreciated in view of the present disclosure that theacoustic reflectometer that is integrated into the ventilator at thehose connection or in the hose itself may be in addition to, or as areplacement for, the acoustic reflectometer located near the proximalend of the ETT.

Providing Insights into Ventilator Trending Parameters

Ventilators report trends of different parameters such as peakinspiratory pressure (PIP), airway compliance, respiratory rate (RR),etc. When these values change over time, it is not always clear if thechange is related to the patient's condition, factors associated withthe artificial airway, or both.

Providing the ability to view ventilation trended variables in concertwith the information from the acoustic reflectometry system (includingthe real-time R_(TUBE) and P_(TRACHEA) calculated as describedhereinabove) provides the clinician with a new means to observecorrelations between artificial airway issues and changing trendingparameters. This information can help the clinician to better understandsome of the subtle changes present with auto modes and compensationmodes as they relate to changes in patient and artificial airway status.

One example of providing insights into ventilator trending parameters isusing trended information from the acoustic reflectometry system tounderstand why peak pressure has increased over time during volumeventilation. Increased peak pressure can be caused by a number of verydifferent conditions, each of which results in a different response bythe clinician. if the increase is due to an increased ETT resistance,then the response would be to remove the constriction from the ETT. Ifthe increase is due to endobronchial intubation, then the response wouldbe to reposition the ETT tip above the carina. If the increase is due toa mechanical change in the patient airways (such as bronchoconstriction)then the response would be to administer a bronchodilator. All of theseconditions can be inferred from trends of R_(TUBE), P_(TRACHEA), ETT tipposition, and passageway size around ETT tip, in conjunction with thepeak pressure. if the increased peak pressure is accompanied by anincreased R_(TUBE) or a lack of increased P_(TRACHEA) then it could beinferred that an increased ETT resistance (e.g. mucus obstruction, tubekinking, or patient biting) and not mechanical changes in the patientairways may be contributing to the increased peak pressure.Alternatively, if the increased peak pressure is accompanied by both anETT tip position that is very low in the trachea and a decreasedpassageway size around the ETT tip, then it could be inferred thatendobronchial intubation and not mechanical changes in the patientairways may be contributing to the increased peak pressure. If theincreased peak pressure does not correlate to any of the trendedinformation available from the acoustic reflectometry system, then itcould be inferred that mechanical changes in the patient airways may becontributing to the increased peak pressures.

Another example of providing insights into ventilator trendingparameters is using trended information from the acoustic reflectometrysystem to understand why tidal volume has decreased over time duringpressure ventilation. As with increased peak pressures during volumeventilation, decreased tidal volume can be caused by a number of verydifferent conditions, each of which results in a different response bythe clinician. If the decrease is due to an increased ETI' resistance,then the response would he to remove the constriction from the ETT. Ifthe decrease is due to endobronchial intubation, then the response wouldbe to reposition the ETT tip above the carina. If the decrease is due toa mechanical change in the patient airways (such as bronchoconstriction)then the response would be to administer a bronchodilator. As wasdiscussed above, all of these conditions can be inferred from trends ofR_(TUBE), P_(TRACHEA), ETT tip position, and passageway size around ETTtip, in conjunction with the tidal volume.

Secretion Management

A recommendation for suctioning the ETT can be generated based upon thevalue, and optionally the trend, of the artificial airway resistance asmeasured by the acoustic reflectometry system.

Furthermore, ventilators typically have a specific “mode” that can heinvoked for suctioning (e.g., for performing pre-oxygenation,post-oxygenation, etc). Pre-suctioning and post-suctioning measurementsfor tube resistance may he analyzed and used as a basis for a messagethat indicates that the suctioning effort was successful or notcompletely successful. This, in turn, could alert the caregiver to driedsecretions that are not removed by regular suctioning and might be anindication for ETT replacement, increased humidification, or otherinterventions such as use of a “tube rescue” device which removes mucusdebris from walls of the ETT lumen. Examples of tube rescue devicesinclude CAM Rescue Cath (available from Omneotech, 92300 OverseasHighway, Suite 208, Tavernier, Fla. 33070) and endOclear (available fromEndoclear, LLC, 2390 Mitchell Park Drive B, Petoskey, Mich. 49770).

Cough Detection to Reduce Nuisance Alarms

Patient coughs are significant as they relate to both high pressurealarms and secretion management. The microphones in the acousticreflectometry system can be used to detect a patient cough event, andthis information can be supplied to the ventilator to discriminate forthose events. For example, this can be embodied as a “count but ignorecough events” option in the ventilator alarm settings, with the benefitof reducing nuisance alarms.

Cough Detection for Secretion Management

When a cough is detected by the acoustic reflectometry system, acomparison may be made of the ETT condition before and after each coughevent in order to assess the effectiveness of the cough as a means formoving secretions (based on the migration of the location of measuredEll obstructions before and after the cough).

Integration of the Acoustic Reflectometry System Into Other AirwayDevices

Integration of acoustic reflectometry system information into a medicaldevice is not limited to only ventilators. For example, heatedhumidifiers can benefit from acoustic reflectometry system information.Issues involving humidifiers are mostly related to rainout, insufficienthumidification leading to dried secretions, and general hygiene. Theacoustic reflectometry system information relating to the size andlocation of obstructions offers manufacturers of humidifiers a means todetect specific humidifier-related issues and either direct theclinician to the problem or automatically make device settingadjustments to attempt to address the problem.

Although the teachings of the present disclosure have been described indetail with reference to certain embodiments, variations andmodifications exist within the scope and spirit of these teaching asdescribed and defined in the following claims:

What is claimed is:
 1. A system for use of acoustic reflectometry inventilation devices, the system comprising: a sound generator to emitsound waves into an endotracheal tube (“ETT”); at least one soundreceiver to detect returning acoustic reflections; at least oneprocessor and memory coupled to the sound generator and at least onesound receiver, the memory including instructions to cause the at leastone processer or to analyze timings and amplitudes of the returningacoustic reflections to determine a location and size of an ETTobstruction and to calculate flow resistance within the ETT and toestimate a pressure drop across the ETT using the calculated flowresistance when a patient spontaneously breathes.
 2. The system of claim1, further comprising a pressure sensor and a flow sensor in an airwaycircuit.
 3. The system of claim 1, further comprising a pressure sensoryand flow sensor in an airway circuit, wherein the memory includesinstructions to cause the at least one processor to determine a pressurewithin the trachea based on an algorithm that implements an equationgenerally of the form:P _(TRACHEA) =P _(AW) −R _(TUBE)×Flow, where P _(TRACHEA)=trachealpressure, P _(AW)=mean pressure at a Y-piece, R _(TUBE)=flow resistanceparameter, Flow=airway flow.
 4. The system of claim 3, wherein thememory includes instructions to cause the at least one processor receivemanual input from a user to obtain a trachea pressure that is above, at,or below a desired baseline pressure, when the user is monitoringreal-time tracheal pressure calculated using the algorithm.
 5. Thesystem of claim 3, wherein the system is configured to display a firstset of work of breathing (“WOB”) parameters based on an actual WOB shareof a patient verses the ventilation device and a second set of WOBparameters based on the algorithm, wherein a comparison of the first setof parameters with the second set of parameters is indicative of apatient's readiness for weaning off the ventilation device.
 6. Thesystem of claim 2, wherein the system further comprising an alarm thatis issued when a predetermined high pressure is detected and, whereinthe system is further configured to determine a possible cause of thehigh pressure alarm and to display information that there is a partialobstruction detected in the ETT, the ETT tip is partially occluded, apossible mainstem bronchial intubation, or any combination thereof. 7.The system of claim 2, wherein the system further comprising an alarmthat is issued when a predetermined low volume is detected, wherein thesystem is further configured to determine a possible cause of the lowvolume alarm and to display information that there is a possiblemainstem bronchial intubation, a possible collapsed lung, a possiblebronchial plug, or any combination thereof.
 8. The system of claim 1,wherein the system further comprising an alarm using a hierarchy that isdetermined by acoustic reflection information.
 9. The system of claim 3,wherein the system is configured to simultaneously display ventilationtrended variables along with trended tracheal pressure calculated by thealgorithm, trended ETT resistance calculated by the algorithm, trendedETT obstruction percentage, trended passageway size around the ETT tip,trended relative movement of the ETT tip within a trachea, or anycombination thereof to assist the user in diagnosing changes in theventilation trended variables.
 10. The system of claim 3, wherein thesystem is configured to indicate when to suction the ETT based on atrend of the resistance parameter calculated using the algorithm.
 11. Asystem for use of acoustic reflectometry in ventilation devices, thesystem comprising: a sound generator to emit sound waves into anendotracheal tube (“ETT”); at least one sound receiver to detectreturning acoustic reflections; a reflectometry device having acontroller for analyzing timings and amplitudes of the returningacoustic reflections to determine a size of a passageway around an ETTtip, location and size of ETT obstructions, relative movement of the ETTtip within a trachea, or any combination thereof; and a ventilationdevice having a pressure sensor and a flow sensor in an airway circuitand being configured to analyze the data from the pressure sensor andflow sensor, and to issue an alarm when a predetermined high pressure isdetected, and being further configured to determine a possible cause ofthe high pressure and to display information that there is a partialobstruction detected in the ETT, the ETT tip is partially occluded, amainstem bronchial intubation, or any combination thereof.
 12. Thesystem of claim 11, wherein displaying information includes displaying atrend of ETT tip position over time.
 13. The system of claim 11, whereindisplaying information includes displaying a trend of ETT resistanceover time.
 14. A system for use of acoustic reflectometry in ventilationdevices, the system comprising: a sound generator to emit sound wavesinto an endotracheal tube (“ETT”); at least one sound receiver to detectreturning acoustic reflections; a reflectometry device having acontroller for analyzing timings and amplitudes of the returningacoustic reflections to determine a size of a passageway around an ETTtip, location and size of ETT obstructions, relative movement of the ETTtip within a trachea, or any combination thereof; and a ventilationdevice having a pressure sensor and a flow sensor in an airway circuitand being configured to analyze the data from the pressure sensor andflow sensor, and to issue an alarm when a predetermined low volume flowis detected, and being further configured to determine a possible causeof the low volume flow and to display information that there is apossible mainstem bronchial intubation, a possible collapsed lung, apossible bronchial plug, or any combination thereof.
 15. The system ofclaim
 14. wherein displaying information includes a change in the airwaysonic reflection morphology.
 16. The system of claim 14, whereindisplaying information includes a change in the size of the passagewaydetected distal of the ETT tip over time.
 17. A system for use ofacoustic reflectometry in ventilation devices, the system comprising: asound generator to emit sound waves into an endotracheal tube (“ETT”);at least one sound receiver to detect returning acoustic reflections; areflectometry device having a controller for analyzing timings andamplitudes of the returning acoustic reflections to determine a size ofa passageway around an ETT tip, location and size of ETT obstructions,relative movement of the ETT tip within a trachea, or any combinationthereof; and a ventilation device having at least one processor andmemory and including a second sound generator, sound receiver, or anycombination thereof, within a ventilator hose or the ventilation deviceto detect faults including the location and severity of hose kinking,the location and severity of hose occlusion due to the pooling ofcondensation in the hose, hose partial or full disconnection location,or the presence or absence of airway circuit devices.
 18. The system ofclaim 17, wherein the reflectometry device is configured to displayinformation including the location and severity of the hose occlusion.19. The system of claim 17, wherein the reflectometry device isconfigured to display information including the hose partial or fulldisconnection location.
 20. The system of claim 17, wherein thereflectometry device is configured to display information including thelocation and severity of the hose kinking.